Provider Demographics
NPI:1245487107
Name:STREETER, CHARLENE A (LPN)
Entity type:Individual
Prefix:
First Name:CHARLENE
Middle Name:A
Last Name:STREETER
Suffix:
Gender:F
Credentials:LPN
Other - Prefix:
Other - First Name:
Other - Middle Name:
Other - Last Name:
Other - Suffix:
Other - Last Name Type:
Other - Credentials:
Mailing Address - Street 1:18 BENNETT ST
Mailing Address - Street 2:
Mailing Address - City:CANASERAGA
Mailing Address - State:NY
Mailing Address - Zip Code:14822-9753
Mailing Address - Country:US
Mailing Address - Phone:607-545-8961
Mailing Address - Fax:
Practice Address - Street 1:4638 NOBLES RD
Practice Address - Street 2:
Practice Address - City:BELMONT
Practice Address - State:NY
Practice Address - Zip Code:14813-9722
Practice Address - Country:US
Practice Address - Phone:585-268-7240
Practice Address - Fax:
Is Sole Proprietor?:No
Enumeration Date:2008-08-22
Last Update Date:2008-08-22
Deactivation Date:
Deactivation Code:
Reactivation Date:
Provider Licenses
StateLicense IDTaxonomies
NY277973-1164W00000X
Provider Taxonomies
Primary?CodeTypeClassificationSpecialization
Yes164W00000XNursing Service ProvidersLicensed Practical Nurse